These changes will affect everyone in your family who gets health care through an Ohio Medicaid managed care plan (MCP).
Starting February 1, 2010, Ohio Medicaid will pay for your prescription drugs and some prescription medical supplies at the pharmacy (diabetic supplies, inhaler spacers, peak flow meters, syringes, needles, alcohol wipes, and condoms). Your MCP will no longer pay for them. You may have to pay a co-payment for some prescription drugs. There are no other changes. You will still get your other health care through your MCP.
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You must use the new member identification (ID) card that your MCP will send you.
You must use your new card to get prescriptions at the pharmacy and to get other health care through your MCP starting February 1, 2010. Your new card lets pharmacies know that Ohio Medicaid will pay for your prescriptions. Contact your MCP if you do not receive your new card by January 31, 2010.
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You can get your prescriptions drugs and medical supplies at any pharmacy that accepts Ohio Medicaid.
Ohio Medicaid will only pay for prescriptions you get from pharmacies that accept Ohio Medicaid. Most pharmacies in Ohio accept Ohio Medicaid. But some out-of-state and mail-order pharmacies do not. Ask your pharmacy if they accept Ohio Medicaid. If you plan to travel out-of-state, be sure to fill your prescriptions before you leave.
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You can keep getting your prescription medical supplies (diabetic supplies, inhaler spacers, peak flow meters, syringes, needles, alcohol wipes, and condoms) at no cost to you.
The pharmacy cannot charge you for these prescription medical supplies.
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You may be able to keep getting all your prescription drugs at no cost to you.
The pharmacy cannot charge you a co-payment for most generic prescription drugs or for a few brand-name prescription drugs. In any case, the pharmacy cannot charge a co-payment for any prescription drugs for a person who is:
- younger than 21,
- pregnant or her pregnancy ended recently (up to 90 days after her pregnancy ends),
- receiving hospice care,
- in a nursing home or an intermediate care facility for the mentally retarded,
- given the prescription as a family planning service (such as contraceptives or prenatal vitamins),
- given the drug during emergency care in a hospital, clinic, office or other facility, or
- given the drug in a doctor's office, hospital outpatient department, clinic, dialysis center, infusion center or during some other medical encounter.
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If you are not eligible to get a prescription drug at no cost to you, the pharmacy will charge you a $2 or $3 co-payment for it.
The pharmacy will charge you a $2 co-payment for most brand-name prescription drugs or $3 for a generic or brand-name prescription drug that requires Ohio Medicaid prior authorization. Ask your doctor or pharmacy if there is another prescription that will work for you that will be at no cost to you or that does not require prior authorization.
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A pharmacy should not charge you more than $3 for a prescription drug.
A pharmacy should not charge you more than $3 for a prescription drug unless you sign an agreement to do so. Before you agree to pay more than $3: (1) ask your doctor or pharmacy if there is another prescription drug that will work for you that does not require prior authorization or is no cost to you, or that has a co-payment of only $2 or $3, or (2) ask your doctor to get prior authorization.
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If you cannot afford a co-payment, you can still get your prescription drug.
If you tell the pharmacy you are unable to pay a co-payment, the pharmacy cannot refuse to give you a prescription drug. But you will still owe the co-payment to the pharmacy. The pharmacy can bill you for an unpaid co-payment. In the future, the pharmacy may refuse to give you a prescription if (1) you still owe an unpaid co-payment and (2) the pharmacy's routine business practice is to deny services to everyone who owes them an unpaid bill. If the pharmacy intends to refuse services because you owe an unpaid co-payment, the pharmacy must tell you.
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Ohio Medicaid requires your doctor to get prior authorization for some prescription drugs.
Ohio Medicaid will not pay for some prescription drugs unless it gave your doctor prior authorization for the prescription.
- If Ohio Medicaid requires prior authorization for one of your prescription drugs and your doctor has gotten it, the pharmacy will charge you a $3 co-payment for the prescription.
- If Ohio Medicaid requires prior authorization for one of your prescriptions but your doctor has not gotten it, the pharmacy will tell you that Ohio Medicaid will not pay for prescription unless your doctor gets prior authorization. If you need to fill the prescription immediately but your doctor is not available to get prior authorization, ask the pharmacy about giving you a short-term supply of the prescription.
Ask your doctor or pharmacy if there is another prescription that will work for you that does not require Ohio Medicaid prior authorization or that is at no cost to you.
Between February 1, 2010 and April 30, 2010, the pharmacy can refill a prescription that usually requires Ohio Medicaid prior authorization if Ohio Medicaid or an MCP paid to fill the prescription on or after August 1, 2009. But, the pharmacy cannot refill the prescription after April 30, 2010, unless your doctor gets Ohio Medicaid prior authorization. If you refill a prescription during February, March or April 2010 for a drug that needs Ohio Medicaid prior authorization, you will receive a letter from Ohio Medicaid giving you information about what your doctor needs to do.
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If you are pregnant, after your baby is born your county Medicaid caseworker must add your baby to your Medicaid case before Ohio Medicaid will pay for prescriptions for your baby.
Ask your caseworker for instructions about how to report when your baby is born. When your baby is born, report to your caseworker as instructed so your caseworker can add your baby to your case. Ask your caseworker to add your baby to your Medicaid case quickly. Your MCP will provide all other health care for your baby as soon as your baby is born.
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More information and help is available.
Questions or problems with your prescription coverage or pharmacy? Phone the Ohio Medicaid Consumer Hotline at 1-800-324-8680 or TTY 1-800-292-3572. The Hotline is open: 7am-8pm Monday-Friday and 8am-5pm Saturday.
Questions or problems with your doctor? Phone member services at your MCP by dialing the toll-free number on your member ID card.
Lists of prescriptions that are available at no cost to you, have co-payments, or require prior authorization at http://jfs.ohio.gov/ohp/bhpp/meddrug.stm.
Co-payments rules, Ohio Administrative Code rules 5101:3-1-09 and 5101:3-9-09 (to be effective February 1, 2010), are available at http://www.registerofohio.state.oh.us.
You may ask for a State Hearing if you think the pharmacy incorrectly charged a co-payment or if you think Ohio Medicaid incorrectly denied prior authorization. To ask for a State Hearing, phone 1-866-635-3748 and follow the instructions for State Hearings.